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ip <br /> SAN '.IOAQUIN COUNTYENVIRONMENTAL HEALTH DEPARTM NT Q LOOPP <br /> 600 East Main Street, Stockton, CA 95202-3029 � E �YE13 <br /> Telephone: (209) 468-3454 Fax: (209) 468-3433 Web: www.siaov-Ora/ehd <br /> WELL & BORING PERMIT APPLICATION APR 2 6 2011 <br /> FOR WELLS AND BORINGS USED FOR CONTAMINANT INVESTIGATIONS AND REM <br /> NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED WO&MPERMIS TAL HEALTH <br /> Application is hereby made to San Joaquin County for a permit to construct and/or install the work described. This application is made in compliance with San <br /> Joaquin County Development TitleLCross Street 04k <br /> ,,Chapter 9-1115.3,and the Standards of the San Joaquin County Environmental Health Department. <br /> Site Ntion 630 .c'11;1"rn"Ik5 4 <br /> PropertyCity �ac�17-On Zi ��QQ <br /> p 57-07- APN 17716510 <br /> Owner SaAJCpra9�jh_ �oH,n.'ryAddress Eas7H/'ebtr/�1tn 6 ,5 0+ g52G�2 <br /> C-57 Contractor I'i SG/� p!'(/1irw, Address City .S1"ac/rTon Zip Phone2d9 #-9625 <br /> �_ 3l 50 Jahnsa„ lid Cay H d•�n11GCALic 6%63945 Phone(7o7)769-9601 <br /> Consultant/Sub Cntr1COnc(oT th Address ISR F/-A ti eiLe' �1-�7Cay Sr�ck �ic 73107 Phon <br /> Billable Party SOAapr Address fa, hWCSTC ,9- Ity crrv'dn ZI T32o26 `n2i – <br /> GIS Coordinates:X 6335093 y-?-179-169 P Phone(?o4)23Y-a5/$ <br /> CONSTRUCTION WORK TO BE PERFORMED <br /> JR NEW WELL/BORING(CPT,GE OP ZE00.HYDROPJ1NC,SH�AN�DLAUG�j OTHER) <br /> ❑ SOIL BORING IDs 3 j, ,S /S <br /> ❑WELL IDs <br /> ❑OTHER IDs <br /> TYPE&#OF WELLISORING INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br /> _❑MONITORING ❑HOLLOW STEM DIA.OF BOREHOLE 2-In-A0 MULTIPLE CASINGS 0 MULTI-LEVEL WELL CASING DIA: _ <br /> EXTRACTION:Vapor/Water 0 HAMMER/DRIVEN CASING THICKNESS TYPE OF CASING: ❑STEEL PVC ❑ OTHER <br /> _❑SOIL VAPOR PROBE ❑MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: [I AUGERS ❑HOSE ❑PIPE <br /> 3[ SOIL BORING APUSH POINT(GP/CPT) GROUT SEAL PUMPED:0 Yes 29 <br /> No(MAXIMUM FREE FALL DEPTH IS 30 FT) <br /> _❑INJECTION(i.eAir Soarae 0,,n,)❑HAND AUGER GROUT SPECIFICATIONS YI rC-A.'r C"" <br /> p ryte n '1^ <br /> _❑OTHER: ❑OTHER: APPROX.BORING DEPTH 3 L "—F ❑BOLTED TRAFFIC BOX OR STOVE PIPE <br /> COMMENTS: O!AT— Vs — Ira CON'UU TOR C SI 0 No Y s:Ca 'ng Dia: Casing Depth:_ Bonng Dia: _ <br /> hL1T v fn/< <br /> NOTE OFFSITE WELLS& BORINGS REQUIR ACCESS AGREEMENTS OR ENCROACHMENT PERMITS <br /> DESTRUCTION WORK TO BE PERFORMED: <br /> #OF WELL(S)TO BE DESTROYED DESTRUCTION METHOD-(CHECK ALL THAT APPLY) <br /> WELL IDs: ❑OVER-BORE DIAMETER OF INCHES TO DEPTH OF FT <br /> GROUTS [IPRESSURE GROUT To DEPTH DF FT BELOW SURFACE <br /> TREMIE TYPE TO BE USED. ❑AUGERS HOSE PIPE E] EX FROM TO FTSELOW SURFACE <br /> COMMENTS El MUSHROOM CAP ATL3 FT) FT BELOW SURFACE <br /> 5 WORKING DAYS NOTICE REQUIRED(AFTER PERMIT ISSUANCE) FOR INSPECTION APPOINTMENTS <br /> — <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, Rules and <br /> Regulations,a all applicable a Caljfoylyyja laws. �J <br /> Signed I/r t/shy[/f� Tkle/CompanN , ojSoc ,ctd �j,ea�pgi f��CQn ctO e— <br /> Print Name i 1l {J C oalr � 6 <br /> Date <br /> DEPARTMENT USE ONLY <br /> SITE MAP IN UNIT IV FILE-SITE ADDRESS <br /> WORK PLAN DATED 4 <br /> APPLICATION ACCEPTED BY <br /> DATE ISSUED 2.� AREA <br /> GROUT INSPECTION BY S S FINAL INSPECTION BY <br /> DESTRUCTION INSPECTION BY DATE <br /> COMMENTS/CONDITIONS: DATE <br /> ACCOUNTING ONLY: AID# FAC# <br /> PE CODES FEE INFO AMT REMITTED CHECK# RECV'D BY DATE SERVICE RO# <br /> p REQUEST PR# INVOICE <br /> I O't $122 x 2-2L Q7 7,b <br /> y z3R# 6a4o <br /> 3�<009 1 zbL RO# <br /> 3500 <br /> PR# <br /> 2900 <br /> C-57 WC WAIVER C-57 LETTER OF AUTHORIZATION TO SIGN PERMIT <br /> EHD 29-01 07/28/10 J�ENCROACHMENT DOC <br /> WELL PERMIT APP <br />